Provider Demographics
NPI:1003061763
Name:GARDNER, ADRIENNE NICHOLE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:NICHOLE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 TRUMPETER AVE
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7913
Mailing Address - Country:US
Mailing Address - Phone:907-398-5193
Mailing Address - Fax:
Practice Address - Street 1:265 N BINKLEY ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7523
Practice Address - Country:US
Practice Address - Phone:907-262-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-22
Last Update Date:2008-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK922491172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker